The Impact of Education and Prospective Audit and Feedback on Reducing Ciprofloxacin Utilization at a Small Community Academic Hospital

Background: Fluoroquinolones have been associated with severe and even disabling side effects. Increasing resistance has rendered these agents less favorable for empiric therapy. In light of these concerns and in response to a period of above-average use at a small community-based academic hospital, we implemented a quality improvement initiative to reduce utilization of ciprofloxacin.

Methods: The multidisciplinary Antibiotic Stewardship Program (ASP) at Barnes-Jewish West County Hospital, a 77-bed facility, developed and disseminated guidelines for ciprofloxacin use to all physicians via an electronic newsletter and in-person meetings with provider groups identified as having high ciprofloxacin utilization rates beginning in 6/2017. Included in the guidelines were recommendations for more effective, safer alternatives to ciprofloxacin for common infection types. In 12/2017, the ASP pharmacist initiated prospective audit and feedback (PAF) for all ciprofloxacin orders. Ciprofloxacin utilization was measured monthly in days of therapy (DOT)/1,000 patient (pt) days utilizing medication administration data. Patient days were determined according to National Healthcare Safety Network (NHSN) conventions.

Results: During the pre-intervention period (6/2015 to 6/2017), ciprofloxacin utilization rates averaged 73.3 DOT/1000 pt days, but in May 2017, use increased to 138.3. Following provider education, average utilization decreased to 56.9 DOT/1000 pt days from 9/2017 to 11/2017. With the addition of PAF, average ciprofloxacin utilization decreased to 43.6 DOT/1000 pt days from 12/2017 to 3/2018, a 41% reduction compared to the pre-intervention period. Utilization of other fluoroquinolones did not increase.

Conclusion: Education was a useful tool in reducing inappropriate ciprofloxacin use; however, a combination of prospective audit and feedback with education achieved the greatest impact on curbing ciprofloxacin use. This multimodal approach was effective and sustainable at a small hospital with limited antibiotic stewardship resources.